More and more young girls seek help for mental problems. “Generally, girls take things more seriously than boys. This applies to school, friends and family,” says researcher Anders Bakken.

“We see that the share of young girls between the age of fifteen and twenty who seek help for mental disorders is increasing,” says Anne Reneflot. She is Department Director at Norwegian Institute of Public Health and one of the authors behind a new report on mental health in Norway.

Today, seven per cent of all girls between the age of fifteen and seventeen, and nine per cent between eighteen and twenty are diagnosed with mental disorders. Over the past years, the amount of girls within the age group who are prescribed anti-depressants have doubled from approximately one to two per cent.

Gender differences

Forty per cent more seek help than five years ago.

“The most common mental problems among girls in this age group are anxiety, depression, eating disorders and adjustment difficulties,” she says.

The report does not show the same pattern among boys in the same age group. Instead, boys with mental disorders are more often diagnosed before they reach puberty, and have a higher risk of being diagnosed with ADHD, autism and Tourette’s syndrome.

“In addition to an increase in young girls who seek help, we also see a rise in the use of anti-depressants.”

“Do you know anything about why more young girls seek psychiatric help?”

“No. All we know is that more young girls seek help, but we are not certain whether it is because the actual scope of mental illnesses has increased,” says Reneflot.

“It may also have to do with an increased openness in society and awareness of the possibilities for help. And the fact that there are more mental healthcare services. But this is only speculations.”

Adjustment difficulties are among the mental problems for which more and more young girls seek help. These are mental problems triggered by distressing life incidents, according to Reneflot.

“Examples of such distressing life incidents may be changes or problems connected to family or school,” she says.

Not chronic illnesses

“It is important to distinguish between diagnoses and general mental conditions when we talk about youth and mental health. Many people mix these two, particularly in the media,” says sociologist and researcher Anders Bakken at OsloMet – Oslo Metropolitan University.

Bakken has done research on youth since the mid-1990s, and is director of Ungdata (‘Youthdata’). According to him, the increased share of young girls seeking help from the mental healthcare services both receive and deserve much attention. Nevertheless, he is careful to distinguish between diagnosed mental disorders, which according to him apply to a relatively small share of young people, and general mental conditions that apply to many more in certain periods.

“By general conditions, we’re talking about sleeping disorders, anxiety and stress, problems that affect every one in four girls in their mid-teens.”

Bakken emphasises that this may affect schoolwork and quality of life, but for most people they are not lifelong illnesses.

“But we see more and more girls report such conditions. Thus, although we are not talking about chronic diseases, we should definitely take them seriously. And we do. Both municipalities and schools are constantly initiating new measures to prevent mental problems among youth.”

Openness does not explain everything

Bakken is sceptical towards explaining the increase in girls who seek help with more openness about mental problems.

“Some point towards over reporting. Others claim that we pamper the young and make them more vulnerable and less capable of handling hardship. But if this was the only explanation, we would probably have seen an increase of mental problems among all youth,” he says.

“More and more girls report that they have mental problems. At the same time, we see a higher increase among ethnic Norwegian girls than among girls with minority background, and we see a higher increase among those who are unhappy in school than among those who enjoy school.”

“Why do girls struggle more than boys?”

“Some of it may have to do with biological differences between girls and boys. The fact that more girls report mental problems may, for instance, be because girls mature earlier than boys do. Moreover, boys and girls are often socialised in different directions,” says Bakken.

“We also need to remember that there are huge differences between girls; not all girls struggle. And at the same time, there are also many boys who struggle mentally.”

“Whereas relatively few report mental health problems when in primary school, something happens during the first years in lower secondary. In tenth grade, the figures are much higher,” Bakken explains.

Boys are more playful

He believes boys’ and girls’ different attitude to life may be part of the explanation to why girls struggle.

“Girls generally take things more seriously than boys. This applies to school, friends and family. For instance, we see that girls work harder in school and do more homework than boys do. And they feel more pressure from their surroundings.”

If you take life more seriously, chances are bigger that you have more worries, according to Bakken.

“Boys are more playful and have a tendency to dismiss the problems they are facing. If problems arise, many of them just start doing something else instead, or look the other way.”According to Bakken, the questionnaires used by Ungdata has been criticised for not being able to underpin boys’ problems.

“It may have to do with how the questions are formulated. If a question begins with ‘Do you feel that …’, it may perhaps not appeal to boys to the same extent,” says Bakken.“But at the same time, we also pose a lot of gender neutral questions where girls still score higher than boys, such as ‘Have you had sleep disorders?’”

He emphasises that boys face other challenges; for instance, they are more often involved with crime and violence than girls are.

School matters the most

“What factors affect young girls’ mental health?”

“School stands out as an important factor. There is much pressure on school results among Norwegian youth today. Many are very busy at school, with tests and exams. Most Norwegian youth think it is important to get an education,” says Bakken.

“In one survey, we interviewed tenth graders, and two thirds of the girls and one third of the boys reported that they experience much school related pressure.”

Bakken draws lines back to the Knowledge Promotion Reform (Kunnskapsløftet) in 2006, and argues that since then there has been an increased attention towards school performance. “There has been much talk about how Norwegian pupils perform in each region compared to other countries.”

Nevertheless, Bakken does not want to turn school into the big, bad wolf.

“The level of satisfaction is high in Norwegian schools. But it is important to look at how the schools are run and how it affects the pupils. For some it may have negative effects.”

“Many think that girls experience more body-image pressure than boys. In any case, more girls struggle with eating disorders. May this be a reason why more girls struggle?”

“I haven’t done any research on this. But since 2017, Ungdata has included new questions that address body-image issues among other things. So we will know more about this soon.”

Bakken emphasises that many worry that youth, and particularly young girls, experience increased body-image pressure through social media. But social media also have positive effects on the girls.

“Many girls said that they consider social media a free space and a way in which to keep in touch with friends. Nevertheless, having to be always available and having to respond to messages all the time was also a stress factor.”

Increased focus on the body

According to the report from Norwegian Institute of Public Health, the most common problems among young girls who seek help from the mental healthcare services are anxiety, depression, eating disorders and adjustment difficulties. According to Kari Løvendahl Mogstad, it is difficult to determine to what extent eating disorders are caused by increased body-image pressure. She is general practitioner, sports physician, and university lecturer at Norwegian University of Science and Technology (NTNU), and author of the book Kroppsklemma (‘The body squeeze’).

“The causes behind eating disorders are very complex and complicated, and there is a lot we don’t know about the connections here,” she says.

“What characterises people with eating disorders is low self-esteem, and they seek some kind of control over their own thoughts and feelings by controlling their food intake.”

According to Mogstad, the low self-esteem may be caused by difficult emotions and experiences in life that they have not learned to handle in other ways.

“But there is no doubt that the huge and increasing focus on the body and the pressure from society on young people in particular cause more people to have a difficult relation to food. Some of these also develop eating disorders.”

Mogstad refers to both Norwegian and international studies showing that the focus on the body has increased in society in general, and that this affects how we feel.

Affected by social media

“Over the past ten years, since social media entered the scene, we have become far more exposed to pictures of ‘perfect’ bodies and people than we used to,” she says.

“Growing up today, being bombarded with pictures and constantly reminded that you are not good enough, of course does something with most people’s self-esteem and body-image.”

Studies show that the majority of those who develop eating disorders are girls, but Mogstad believes that there is a lot of under-reporting when it comes to boys and eating disorders.

“Boys and girls have different ways of communicating, and it is perhaps not as accepted for a boy to say publicly that he is struggling with eating disorders,” she says.

“Moreover, girls spend much more time on social media and follow various bloggers, celebrities and others who post pictures of slim and perfect bodies, and they are therefore exposed to more influence from these.”

Facts about the report

In January 2018, Norwegian Institute of Public Health published the report ‘Psykisk helse i Norge’ (‘Mental health in Norway’), a revised version of the report ‘Psykiske lidelser i Norge: Et folkehelseperspektiv’ (‘Mental disorders in Norway: A Public Health Perspective’) from 2009.

The purpose has been to provide an updated overview of the occurrence of mental conditions and substance abuse disorders, and contact with the health services relevant for these disorders.

Meta-analysis of 522 trials includes the largest amount of unpublished data to date, and finds that antidepressants are more effective than placebo for short-term treatment of acute depression in adults.

A major study comparing 21 commonly used antidepressants concludes that all are more effective than placebo for the short-term treatment of acute depression in adults, with effectiveness ranging from small to moderate for different drugs.

The international study, published in The Lancet, is a network meta-analysis of 522 double-blind, randomised controlled trials comprising a total of 116477 participants. The study includes the largest amount of unpublished data to date, and all the data from the study have been made freely available online.

“Our study brings together the best available evidence to inform and guide doctors and patients in their treatment decisions. We found that the most commonly used antidepressants are more effective than placebo, with some more effective than others. Our findings are relevant for adults experiencing a first or second episode of depression – the typical population seen in general practice. Antidepressants can be an effective tool to treat major depression, but this does not necessarily mean that antidepressants should always be the first line of treatment. Medication should always be considered alongside other options, such as psychological therapies, where these are available. Patients should be aware of the potential benefits from antidepressants and always speak to the doctors about the most suitable treatment for them individually,” says lead author Dr Andrea Cipriani, University of Oxford and the NIHR Oxford Health Biomedical Research Centre.

An estimated 350 million have depression worldwide. The economic burden in the USA alone has been estimated to be more than US$210 billion. Pharmacological and non-pharmacological treatments are available but because of inadequate resources, antidepressants are used more frequently than psychological interventions. However, there is considerable debate about their effectiveness.

As part of the study, the authors identified all double-blind, randomised controlled trials (RCTs) comparing antidepressants with placebo, or with another antidepressants (head-to-head trials) for the acute treatment (over 8 weeks) of major depression in adults aged 18 years or more. The authors then contacted pharmaceutical companies, original study authors, and regulatory agencies to supplement incomplete reports of the original papers, or provide data for unpublished studies.

The primary outcomes were efficacy (number of patients who responded to treatment, i.e. who had a reduction in depressive symptoms of 50% or more on a validated rating scale over 8 weeks) and acceptability (proportion of patients who withdrew from the study for any reason by week 8).

Overall, 522 double-blind RCTs done between 1979 and 2016 comparing 21 commonly used antidepressants or placebo were included in the meta-analysis, the largest ever in psychiatry. A total of 87052 participants had been randomly assigned to receive a drug, and 29425 to receive placebo. The majority of patients had moderate-to-severe depression.

All 21 antidepressants [1] were more effective than placebo, and only one drug (clomipramine) less acceptable than placebo.

Some antidepressants were more effective than others, with agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine proving most effective, and fluoxetine, fluvoxamine, reboxetine, and trazodone being the least effective. The majority of the most effective antidepressants are now off patent and available in generic form.

Antidepressants also differed in terms of acceptability, with agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine proving most tolerable, and amitriptyline, clomipramine, duloxetine, fluvoxamine, reboxetine, trazodone, and venlafaxine being the least tolerable.

The authors note that the data included in the meta-analysis covers 8-weeks of treatment, so may not necessarily apply to longer term antidepressant use. The differences in efficacy and acceptability between different antidepressants were smaller when data from placebo-controlled trials were also considered.

In order to ensure that the trials included in the meta-analysis were comparable, the authors excluded studies with patients who also had bipolar depression, symptoms of psychosis or treatment resistant depression, meaning that the findings may not apply to these patients. “Antidepressants are effective drugs, but, unfortunately, we know that about one third of patients with depression will not respond. With effectiveness ranging from small to moderate for available antidepressants, it’s clear there is still a need to improve treatments further,” adds Dr Cipriani, who is also a consultant psychiatrist at Oxford Health NHS Foundation Trust [2].

409 (78%) of 522 trials were funded by pharmaceutical companies, and the authors retrieved unpublished information for 274 (52%) of the trials included in the meta-analysis. Overall, 46 (9%) trials were rated as high risk of bias, 380 (78%) as moderate, and 96 (18%) as low. The design of the network meta-analysis and inclusion of unpublished data is intended to reduce the impact of individual study bias as much as possible. Although this study included a significant amount of unpublished data, a certain amount could still not be retrieved.

“Antidepressants are routinely used worldwide yet there remains considerable debate about their effectiveness and tolerability. By bringing together published and unpublished data from over 500 double blind randomised controlled trials, this study represents the best currently available evidence base to guide the choice of pharmacological treatment for adults with acute depression. The large amount of data allowed more conclusive inferences and gave the opportunity also to explore potential biases,” says co-author Professor John Ioannidis, from the Departments of Medicine, Health Research and Policy, Biomedical Data Science, and Statistics, Stanford University, USA [2].

The authors note that they did not have access to individual-level data so were only able to analyse group differences. For instance, they could not look at the effectiveness or acceptability of antidepressants in relation to age, sex, severity of symptoms, duration of illness or other individual-level characteristics.

The findings from this study contrast with a similar analysis in children and adolescents, which concluded that fluoxetine was probably the only antidepressant that might reduce depressive symptoms [4]. The authors note that the difference may be because depression in young people is the result of different mechanisms or causes, and note that because of the smaller number of studies in young people there is great uncertainty around the risks and benefits of using any antidepressants for the treatment of depression in children and adolescents.

[1] All second-generation antidepressants approved by the regulatory agencies in the USA, Europe and Japan were included in the study: agomelatine, bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, paroxetine, reboxetine, sertraline, venlafaxine, vilazodone, and vortioxetine. To inform clinical practice globally, the two tricyclics (amitriptyline and clomipramine) from the WHO Model List of Essential Medicines were included. Finally, trazodone and nefazodone, were also included because of their distinct effect and tolerability profiles.

A new study in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging looks at the modulation of emotion in the brain

A new study published in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging reports that processing of negative emotion can be strengthened or weakened by tuning the excitability of the right frontal part of the brain.

Using magnetic stimulation outside the brain, a technique called repetitive transcranial magnetic stimulation (rTMS), researchers at University of Münster, Germany, show that, despite the use of inhibitory stimulation currently used to treat depression, excitatory stimulation better reduced a person's response to fearful images.

The findings provide the first support for an idea that clinicians use to guide treatment in depression, but has never been verified in a lab. "This study confirms that modulating the frontal region of the brain, in the right hemisphere, directly effects the regulation of processing of emotional information in the brain in a 'top-down' manner," said Cameron Carter, M.D., Editor of Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, referring to the function of this region as a control center for the emotion-generating structures of the brain. "These results highlight and expand the scope of the potential therapeutic applications of rTMS," said Dr. Carter.

In depression, processing of emotion is disrupted in the frontal region of both the left and right brain hemispheres (known as the dorsolateral prefrontal cortices, dlPFC). The disruptions are thought to be at the root of increased negative emotion and diminished positive emotion in the disorder. Reducing excitability of the right dlPFC using inhibitory magnetic stimulation has been shown to have antidepressant effects, even though it's based on an idea-that this might reduce processing of negative emotion in depression-that has yet to be fully tested in humans.

Co-first authors Swantje Notzon, M.D., and Christian Steinberg, Ph.D, and colleagues divided 41 healthy participants into two groups to compare the effects of a single-session of excitatory or inhibitory magnetic stimulation of the right dlPFC. They performed rTMS while the participants viewed images of fearful faces to evoke negative emotion, or neutral faces for a comparison.

Although the study was limited to healthy participants, senior author Markus Junghöfer, Ph.D., notes that "...these results should encourage more research on the mechanisms of excitatory and inhibitory magnetic stimulation of the right dlPFC in the treatment of depression."

Virtual reality-based cognitive behavioural therapy (CBT), in addition to usual treatment, can reduce paranoia and anxiety in people with psychotic disorders, according to the first randomised controlled trial of its kind, published in The Lancet Psychiatry.

The study of 116 people with psychosis across seven Dutch mental health centres suggests that virtual reality CBT does not immediately lead to participants spending more time with others, but helps them have more positive interactions by reducing anxiety and paranoia. All participants continued with their usual treatment (medication and therapy) during the trial.

While the trial shows promising early results, more research will be needed to confirm the long-term effects of virtual reality CBT before the treatment becomes widely available.

As many as 90% of people with psychosis have paranoid thoughts, such as beliefs that there is a threat towards them, or that others wish to cause them harm. As a result, many people with psychosis avoid public and social activities, have small social networks, and spend more time alone than people without psychosis.

CBT is the most effective psychological treatment for people with psychosis, but its benefits to reduce paranoia and social functioning can be limited.

The virtual reality CBT trialled in this study built on this by creating a controlled virtual environment. All 116 participants continued their treatment as usual, which included antipsychotic medication, regular contact with a psychiatrist, and with a psychiatric nurse to improve self-care, daytime activities, and social and community functioning. Half of the trial participants (58 people) practiced social exercises through a virtual environment with a therapist. The control group (58 people) only received treatment as usual.

The therapy consisted of 16 one-hour sessions over 8-12 weeks, where the therapist exposed the participant to the social cues that triggered their fear, paranoid thoughts, and safety behaviours in four virtual environments (a street, bus, café, and supermarket). The therapist could alter the number of avatars, their appearance, their response to the participant (neutral or hostile), and make them say pre-recorded sentences. The therapist also spoke directly with the participant during the therapy, helping them to explore and challenge their feelings during the virtual social situations, to stop using safety behaviours (such as avoiding eye contact), and challenge their concerns that others wish to harm them.

Social participation was assessed by measuring the amount of time spent with other people, momentary paranoia, perceived social threat, and momentary anxiety. Participants were assessed at the start of the trial, after treatment (at three months), and at six months.

Compared with the control group, virtual reality CBT did not increase the amount of time spent with other people after three months. However, there was a significant difference after six months because the control group spent much less time with others between baseline and six months, while the participants in the virtual reality CBT group slightly increased their time with others.

Participants’ paranoia and anxiety in social situations were also reduced in the virtual reality CBT group, compared to the control group at three months and at six months. However, the treatment did not reduce perceived social threat.

The virtual reality CBT group also used fewer safety behaviours and had fewer social cognition problems at three and six months, which in turn led to fewer paranoid feelings. The authors say that this could be because reducing safety behaviours meant that participants were more attentive and gained more social information from the situation, reducing the likelihood of them incorrectly perceiving a threat and becoming paranoid.

There were no adverse events related to the virtual reality CBT. However, 11 participants in the virtual reality CBT group dropped out of the study, including four who never started treatment and seven who discontinued treatment.

“The addition of virtual reality CBT to standard treatment reduced paranoid feelings, anxiety, and use of safety behaviours in social situations, compared with standard treatment alone,” says lead author, Roos Pot-Kolder, VU University, Netherlands. “It’s important to note that all patients on this trial continued with their usual treatment, and the virtual reality CBT was administered by trained therapists.”

“While we did not find that this therapy increased the amount of time that participants spent with others, we are hopeful that once patients feel more comfortable in social situations and learn that other people are less threatening than anticipated, they might make and maintain social contacts, and find hobbies and jobs. However, more research will be needed before the treatment becomes widely available in the clinic.” [1]

The authors note some limitations, including that the study did not include an active control group so it cannot be ruled out that having an additional treatment alone could have led to the improvements in this group, or that the CBT element of the therapy caused the improvements. The study is also slightly underpowered, and some participants did not take part because they were too frightened to travel to the centre, which means that the sample could be biased.

The controlled environment also does not fully mirror reality as it did not include unexpected surprises, and did not allow full conversations between the participants and the avatars. Finally, more research will be needed to confirm the long-term effects of virtual reality CBT.

Writing in a linked Comment, Dr Kristiina Kompus, Bergen University, Norway, says: “With the development of virtual reality and mobile technology, the range of tools available in psychotherapy is expanding. Use of virtual reality environments in which participants interact with computer-controlled situations or avatars enables a more fine-tuned approach to exposure in the context of cognitive behavioural therapy. Virtual-reality-based exposure therapy is effective for anxiety disorders according to the results of several meta-analyses, with most studies concentrating on simple phobias. It is important to establish whether the benefits that virtual reality can bring to therapy extend to complex challenges involving social cognition, such as positive and negative symptoms or social participation in patients with psychosis.”

There is no evidence to support the practice of parents providing alcohol to their teenagers to protect them from alcohol-related risks during early adolescence, according to a prospective cohort study in Australia published in The Lancet Public Health journal.

The six year study of 1927 teenagers aged 12 to 18 and their parents found that there were no benefits or protective effects associated with giving teenagers alcohol when compared to teenagers who were not given alcohol. Instead, parental provision of alcohol was associated with increased likelihood of teenagers accessing alcohol through other sources, compared to teenagers not given any alcohol.

Alcohol consumption is the leading risk factor for death and disability in 15-24 year olds globally. Drinking during adolescence is of concern as this is when alcohol use disorders (ie, dependence on or abuse of alcohol) are most likely to develop.

“In many countries, parents are a key provider of alcohol to their children before they are of legal age to purchase alcohol. This practice by parents is intended to protect teenagers from the harms of heavy drinking by introducing them to alcohol carefully, however the evidence behind this has been limited,” says lead author Professor Richard Mattick, University of New South Wales, Australia. “Our study is the first to analyse parental supply of alcohol and its effects in detail in the long term, and finds that it is, in fact, associated with risks when compared to teenagers not given alcohol. This reinforces the fact that alcohol consumption leads to harm, no matter how it is supplied. We advise that parents should avoid supplying alcohol to their teenagers if they wish to reduce their risk of alcohol-related harms.”

The study recruited teenagers and their parents between 2010 and 2011 from secondary schools in Perth, Sydney and Hobart (Australia). The teenagers and their parents completed separate questionnaires every year from 2010 to 2016 including information about how teenagers accessed alcohol (from parents, other non-parental sources, or both), binge drinking levels (defined as drinking more than four drinks on a single occasion in the past year), experience of alcohol-related harm, and alcohol abuse symptoms [2]. In the final two years, teenagers were also asked about symptoms of alcohol dependence and alcohol use disorder that could predict alcohol misuse problems in the future.

At the start of the study, the average age of the teenagers was 12.9 years old and by the end of the study the average age was 17.8 years old. The proportion of teenagers who accessed alcohol from their parents increased as the teenagers aged, from 15% (291/1910) at the start of the study to 57% (916/1618) at the end of the study [3], while the proportion with no access to alcohol reduced from 81% (1556/1910) teenagers to 21% (341/1618).

At the end of the study, 81% (632/784) of teenagers who accessed alcohol through their parents and others reported binge drinking, compared with 62% (224/361) of those who accessed it via other people only, and 25% (33/132) of teens who were given alcohol by their parents only. Similar trends were seen for alcohol-related harm, and for symptoms of possible future alcohol abuse, dependence and alcohol use disorders. The group of teenagers supplied with alcohol from both their parents and other sources were at the greatest risk of the five adverse outcomes, potentially as a result of their increased exposure.

Importantly, teenagers supplied with alcohol by only their parents one year were twice as likely to access alcohol from other sources the next year. As a result, the authors suggest that having alcohol supplied by parents does not mitigate risk of it being supplied by other people, and that parental provision of alcohol did not appear to help teenagers deal with alcohol responsibly.

“While governments focus on prevention through school-based education and enforcement of legislation on legal age for buying and drinking alcohol, parents go largely unnoticed. Parents, policy makers, and clinicians need to be made aware that parental provision of alcohol is associated with risk, not with protection, to reduce the extent of parental supply in high-income countries, and in low-middle-income countries that are increasingly embracing the consumption of alcohol.” Says Professor Mattick.

The authors note some limitations, including that teenagers from low socioeconomic status backgrounds – for whom alcohol-related issues are more common – were underrepresented in the study. In addition, the binge drinking measure (defined as drinking more than four drinks on a single occasion in the past year) was conservative, which may affect the associations identified.

The results may not apply to other countries, in particular where there is lower alcohol consumption than Australia, and the research does not account for the amount of alcohol supplied by parents, or the context in which it is given.

Writing in a linked Comment, Professor Stuart Kinner, Murdoch Children’s Research Institute, Australia, says: “An important strength of the study is the careful adjustment for potential confounders. Nevertheless, it is difficult to exclude the possibility that some parents provided alcohol to their children in response to other, unmeasured risk factors, such as alcohol expectancies… Further research is required to better understand why some parents choose to supply their children with alcohol… The findings by Mattick and colleagues strongly suggest that parental supply of alcohol to adolescents does not protect against future alcohol-related harm, and might in fact increase risk. However, before drawing firm conclusions, it will be important to replicate this finding in larger samples that permit more granular characterisation of both exposures and outcomes, and in samples with at least proportionate representation of socioeconomically disadvantaged families. In view of the substantial role of alcohol in the burden of disease for adolescents, evidence-based prevention of alcohol-related harm across the social gradient is crucial."

Data from Netherlands point to the chronic use of antidepressant drugs in general practice in a study published in the current issue of Psychotherapy and Psychosomatics. Antidepressant use is highly prevalent. Research has mainly focused on efficacy during short periods of use for depression and anxiety. There is a relative paucity of data regarding the frequency of long-term use.

To determine the prevalence and possible increase of long-term use of antidepressants over recent years, Authors analyzed routine general practice care data in a large cohort of patients (n = 156,620) in and around Amsterdam, The Netherlands.Results highlighted a substantial prevalence of long-term use of antidepressants. In addition, such use appears to be increasing: 30.3% of use was long-term over the period 1995-2005 compared to 43.7% for the period 2005-2015. Higher age, a registered diagnosis of anxiety or depression, and the use of SSRIs or SNRIs were associated with long-term use of antidepressant drugs. Furthermore, specific antidepressants were differentially associated with long-term use.Authors concluded that long-term antidepressant use is substantial and appears to be on the rise. Awareness of this phenomenon should be increased, such use should be prevented when possible, and reasons for long-term use need to be examined.

A new study published in the current issue of Psychotherapy and Psychosomatics suggests that suicidal ideations and suicide attempts are linked to opioid use and pain sensitivity in the elderly. The recent dramatic increase in opioid prescribing and their inappropriate use has led to an epidemic of opioid addictions, often generalizing to other substance use disorders and overdose deaths. In the US, the suicide death rate with opioid overdose increased from 2.2% in 1999 to 4.4% in 2010.

Authors investigated differences in terms of analgesic consumption and physical pain between (1) subjects with suicidal ideation during follow-up or with a lifetime history of suicide attempt, (2) affective controls, i.e., subjects with a lifetime history of major depression Mini-International Neuropsychiatric Interview (MINI) or high depressive symptoms (Center for Epidemiological Studies-Depression, CES-D >16) during the study but without suicidal ideations/attempts and (3) healthy controls, i.e., having neither suicidal ideations/attempts nor major depression, and having low depressive symptoms and no psychotropic medication use during the study.The proportion of subjects taking analgesics was 37.6% in subjects with suicidal ideations/attempts, 30.2% in affective controls, and 21.6% in healthy controls. A higher rate of analgesic consumption in subjects with suicidal ideation/attempt versus healthy controls was reported. For nonopioid drugs, proportions were 21.8% in subjects with suicidal ideation/attempt, 18.5% in affective controls, and 15.5% in healthy controls; for opioid drugs, they were 15.7% in subjects with suicidal ideation/attempt, 11.7% in affective controls, and 6.1% in healthy controls. Also comparing nonopioid and opioid drug consumption, a difference between subjects with suicidal ideation/attempt and healthy controls was found. When compared opioid users to analgesic nonusers, subjects with suicidal ideation/attempt were more prone to use opioids than healthy controls (suicidal ideations/attempts: odds ratio (OR) = 2.78).These findings point out to the increased consumption of opioids in subjects with suicidal ideation/attempt compared to healthy controls which might suggest an increased sensitivity to psychological and/or physical pain in suicide.

A new study published in the current issue of Psychotherapy and Psychosomatics explores the role of sexuality in the long-term outcome of anorexia nervosa and bulimia nervosa. As with other psychiatric disorders, anorexia nervosa (AN) and bulimia nervosa (BN) are often comorbid with sexual dysfunctions. Different studies suggest that a relevant percentage of persons with EDs continue to display ED psychopathology for protracted periods of time.

This study aimed to evaluate whether sexual functioning may represent a predictor of response to CBT and a potential indicator of the recovery process in patients with AN and BN.Results confirmed that after a psychological intervention focused on the common core psychopathological features of EDs, patients with AN and BN showed similar changes in several domains of sexual functioning. Moreover, the improvement of sexual functioning was associated with a reduction of some specific psychopathological features of EDs, such as body uneasiness. On the other hand, weight restoration and binge-eating reduction appeared to be not directly correlated with these outcomes. In other words, some patients with AN restored to a normal weight but still showed an impaired sexuality, and some patients with BN interrupted binge eating but still reported sexual dysfunctions.These observations confirmed those of previous studies describing a specific relationship between ED psychopathology and sexual dysfunction and partly contradict the hypothesis that sexual dysfunction in AN is exclusively due to weight loss and secondary hypogonadism.

Increasing evidence supports an association between ADHD and various health-risk behaviors

Attention-deficit/hyperactivity disorder (ADHD) increases the risk of subsequent sexually transmitted infections (STIs) among adolescent and young adult populations by about three times, reports a study published in the January 2018 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) The authors also found that short- and long-term use of ADHD medication reduced the risk of subsequent STIs among men by 30% and 41%, respectively."ADHD is the most common neurodevelopmental disorder, and affects approximately 5%-7% of children and adolescents and 2% of young adults," said lead author Mu-Hong Chen, MD, a physician at the Taipei Veterans General Hospital and the College of Medicine, National Yang-Ming University, Taipei. "Increasing evidence supports an association between ADHD and various health-risk behaviors, such as risky driving, substance abuse, and risky sexual behaviors. Clinical psychiatrists [should] focus on the occurrence of risky sexual behaviors and the risk of STIs among patients with ADHD, and emphasize that treatment with ADHD medications may be a protective factor for prevention of STIs."The findings are based on the Taiwan National Health Insurance Research Database, which is a nationally representative database of medical claims and healthcare data from > 99% of the entire Taiwan population.A cohort of 17,898 adolescents and young adults who were diagnosed with ADHD and 71,592 age and sex-matched non-ADHD controls who did not have STIs prior to enrollment were studied.Adolescents aged 12-17 years and young adults aged 18-29 years were followed from January 1, 2001 through December 31, 2009. The researchers tracked data related to risk of STIs, including HIV, syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis, psychiatric comorbidity, and pharmacologic treatment for ADHD (methylphenidate or atomoxetine).The researchers found that adolescents and young adults with ADHD had greater incidence of any STI (1.2% versus 0.4%), and developed STIs at a younger age (20.51 ± 4.48 versus 21.90 ± 4.49) as compared to age- and sex-matched peers.They also found that those adolescents and young adults with ADHD had a higher prevalence of psychiatric comorbidity, including disruptive behavior disorder (13.5% v. 0.3%), alcohol use disorders (1.1% versus 0.5%), and substance use disorders (2.5% versus 0.8%).Male short-term (HR 0.70) and long-term (HR 0.59) ADHD medication users had a significantly lower risk of developing any STI during follow-up.

For children who need help from so-called welfare technology in order to manage their day-to-day lives, it is important that the assistance they get is invisible to others. Many obtain effective help from an app installed on their phones.

Between three and five per cent of primary school-age children have received an ADHD diagnosis, while the occurrence of autism is about 51 in 10,000. The research project Erre mulig? (Is it possible?), coordinated by SINTEF, has been looking into the application of welfare technology for children with these diagnoses.One of the project’s conclusions is that when considering using technology to help these children, it is easy to fall into the “solution-seeking-a-problem” trap instead of adopting a “problem-seeking-a-solution approach”.“In so far as possible, our ideal is that a technical aid can be installed in everyday technology such as a phone or tablet, so that the kids have no need for specially-tailored systems”, says researcher Øystein Dale who has led the project. “Children usually don’t like to be seen as different from everyone else. They want to use the same stuff as other kids do”, he says.“However, once it has been installed, we’ve found that this type of technology can be of great benefit to many families”, he adds. Dale explains that the project has been looking at children who manage their day-to-day lives relatively well in spite of their diagnosis.

Help to organise the day

The researchers have focused in particular on technology that helps children to organise their day-to-day lives, and which supports collaboration and communication between home and school. They have monitored the families, schools and the support services that have tested welfare technology in the municipalities of Nøtterøy (which has been responsible for the project), Tønsberg and Fredrikstad.Many of the families taking part in the project agreed that the mornings in particular were stressful, and that they wanted help in structuring this part of the day. Among other things, the project has tested a number of different calendar-based devices that involve sending out notifications in the form of sounds, texts and/or images to remind children of activities or other tasks they have to do.Twelve-year-old Tine, who has been diagnosed with ADHD, was one of the children described in the report. Tine needs a lot of help from her parents, and the aim was to encourage her to become more independent. The key element of the digital system was to help Tine remember to take her medication at the right time, get to school on time and to establish better lines of communication with her school.Tine agreed with her parents and her teacher that a calendar-based system could be installed on her mobile phone. She was sent reminders about things she had to do during the day by both her parents and teachers. The phone hooted like a car horn every time a notification arrived. Tine had chosen this sound herself. Her parents were able to check whether or not she had followed up on her messages.It emerged that it was important not to send too many notifications because Tine found this to be a nuisance. On the other hand, she was very proud that she had learned how to use the device, and how to enter her own appointments and symbols.

Individual supervision essential

“Many people regarded these calendar-based notifications as very useful”, says Dale. “Kids can spend a lot of energy in remembering things. One of them said ‘now I only have to write it on my smart phone, then I can forget it and the phone will remember for me’”, he says.“We’ve seen how welfare technology can help make people’s day-to-day lives easier, but it’s very important to make a good assessment of the needs of both the child and the family”, says Dale. “There’s no blueprint for how to design welfare technology”, he says, pointing out that there is enormous variation in how children with autism and ADHD function.This of course makes it easier to introduce technology in situations where the child first feels that he or she has an unmet need, and then becomes motivated and experiences the technology as an improvement in his or her everyday life. It is also an advantage if the child is provided with choices.“We see that children with similar challenges and life situations nevertheless respond differently to the same type of technology applied to the same tasks”, says Dale. “Something that works well for one child, will not necessarily work for another”, he says.Technology doesn’t necessarily suit everyone. One of the children experienced the reminders to do things as irritating. He would rather have his parents remind him. Some of the specialists who took part in the project said that there was too much focus on the technology, and not enough on assessing the problem.The researchers recommend that the need for making time for training and follow-up should not be underestimated. It is important to start with a realistic attitude using specific and well-constrained technology, which can then be expanded later.

Municipalities need more knowledge

The municipalities have local responsibility for following up the use of welfare technology and technical aids, with assistance from the NAV Technical Aids Centre. The researchers have found that municipalities need more knowledge about services involving tailored welfare technologies, and about how such technologies can be used to support children and young people with ADHD or autism. This also applies to the adaptation and use of everyday technologies.Before purchasing something new, it is important to investigate what kind of technology the school, the child and the family are already using. It may be the case that everyday devices such as phones, tablets and tools already used by the school can continue to be used if they are adapted correctly. This will make it unnecessary to purchase new equipment.“Traditionally, municipalities have focused mainly on elderly people when it comes to investment in welfare technology”, says Dale. “Things are changing, but the fact that this is a new development can explain why municipalities need to be more aware about the use of welfare technology for younger users”, he says.

Keeping track of time and remembering appointments is not always easy for children with ADHD. Smart watches, smart phones and tablets can be a big help.Source: SINTEF